Elsevier

Child Abuse & Neglect

Volume 30, Issue 11, November 2006, Pages 1239-1255
Child Abuse & Neglect

Linkages between child abuse and attention-deficit/hyperactivity disorder in girls: Behavioral and social correlates

https://doi.org/10.1016/j.chiabu.2006.04.008Get rights and content

Abstract

Objective

The objectives of this study were to examine whether girls with attention-deficit/hyperactivity disorder (ADHD) are at increased risk of having histories of abuse and to assess whether the presence of an abuse history may constitute a distinct subgroup of youth with ADHD.

Method

We examined rates and correlates of child abuse in an ethnically and socioeconomically diverse sample of girls with attention-deficit/hyperactivity disorder (ADHD; n = 140) and a matched comparison sample of girls without ADHD (n = 88), all aged 6–12 years. A thorough chart review reliably established documented rates of physical and sexual abuse in both samples.

Results

There were significantly higher rates of abuse for girls with ADHD (14.3%) than for the comparison sample (4.5%), with most of the abuse found in girls with the Combined as opposed to the Inattentive type. Higher rates of externalizing behaviors (including objective observations in a research summer camp) and peer rejection (indexed through peer sociometric nominations) characterized the subgroup of girls with ADHD with abuse histories compared to the subgroup without such histories, with moderate to large effect sizes. Subgroup differences regarding internalizing problems and cognitive deficits did not emerge. Findings regarding peer rejection were explained, in part, by higher rates of observed aggressive behavior in the abused subgroup.

Conclusions

The findings raise important questions about the possible etiologic and/or exacerbating role of abusive trauma in a subgroup of children with ADHD.

Résumé

Objectif

Cette étude a examiné des fillettes souffrant de troubles déficitaires de l’attention avec hyperactivité à savoir si ce problème les expose à un plus grand risque d’être victimes de maltraitance, et a évalué si une anamnèse de maltraitance parmi ce groupe pourrait constituer une raison pour reconnaître un sous-groupe de jeunes souffrant de ce désordre.

Méthode

Nous avons examiné les taux de maltraitance ainsi que les facteurs qui y sont associés dans une population mixte tant au point de vue ethnique que socioéconomique, de fillettes âgées de 6 à 12 ans et souffrant de troubles déficitaires de l’attention avec hyperactivité (n = 140) et nous les avons comparées à un échantillon de fillettes non atteintes du même désordre (n = 88). Nous avons passé en revue attentivement leurs dossiers afin de confirmer qu’elles avaient été effectivement victimes de maltraitance physique et sexuelle.

Résultats

Les fillettes souffrant de troubles déficitaires de l’attention avec hyperactivité manifestent des taux beaucoup plus élevés de maltraitance (14,5%) que le groupe de comparaison (4,5%), et la plupart des incidents de maltraitance sont du type «combiné» plutôt que du type «inattentif». Les fillettes faisant partie du sous-groupe (désordre + maltraitance) manifestent des taux plus élevés de comportements extériorisés (observés de façon objective, entre autres, dans un camp d’été) et de rejet par leurs paires (mesuré via des jugements sociométriques par leurs paires), comparées au groupe de comparaison. Ces taux sont modérément à largement plus élevés. Aucune différence n’a été observée concernant les problèmes d’intériorisation et les déficits cognitifs. Les constats portant sur le rejet par les paires s’expliquent en partie par les taux plus élevés de comportement agressif parmi les fillettes du sous-groupe.

Conclusions

Les constats soulèvent des questions importantes à savoir l’étiologie possible et/ou le rôle exacerbant des traumatismes causés par la maltraitance, dans un sous-groupe d’enfants souffrant de troubles déficitaires de l’attention avec hyperactivité.

Resumen

Objetivo

Los objetivos de este estudio fueron el examinar si niñas con trastorno por déficit de atención con hiperactividad (TDAH) tienen un mayor riesgo de haber sufrido una historia de maltrato y evaluar si la presencia de una historia de maltrato permite constituir un subgrupo distinto de jóvenes con TDAH.

Método

Se examinaron las tasas y correlatos de maltrato infantil en una muestra de chicas con TDAH (n = 140), con diversidad étnica y socioeconómica, y en un grupo comparación emparejado formado por chicas sin TDAH (n = 88). En ambos grupos las niñas tenían edades entre 6 y 12 años. A través de una revisión fiable de los archivos se establecieron las tasas documentadas de maltrato físico y abuso sexual en ambos grupos.

Resultados

Se observaron tasas significativamente más altas de maltrato para las chicas con TDAH (14.3%) que para el grupo comparación (4.5%). En el grupo clínico las mayores tasas de historia de maltrato se observaron en las chicas con el subtipo combinado que en las del subtipo que presentan sólo trastorno de atención. Las tasas elevadas de conductas externalizadas (incluyendo observaciones objetivas llevadas a cabo en un campamento de verano) y de rechazo por los iguales (evaluadas a través de nominaciones sociométricas de los iguales) caracterizaron al subgrupo de chicas con TDAH e historia de maltrato comparado con el subgrupo de chicas con TDAH sin historia de maltrato. Las diferencias entre ambos grupos presentaron tamaños del efecto entre moderados y elevados. No aparecieron diferencias entre los subgrupos en relación con problemas internalizados y déficit cognitivos. Los hallazgos relacionados con el rechazo de los iguales fueron explicados, en parte, por las altas tasas observadas de conducta agresiva en el subgrupo con historias de maltrato.

Conclusiones

Los hallazgos sugieren cuestiones relevantes acerca de la posible etiología y/o del papel que desarrolla el maltrato infantil en un subgrupo de niños que presentan Trastorno por Déficit de Atención con Hiperactividad.

Introduction

The behavioral sequelae of child abuse and the symptoms and outcomes of children with attention-deficit/hyperactivity disorder (ADHD) share many features, including aggression and externalizing behavior, depression, and cognitive difficulties (e.g., Ethier, Lemelin, & Lachorite, 2004; Mannuzza & Klein, 1999). This overlap has sparked a recent debate as to the possible association between ADHD and child abuse (Ford et al., 2000, Wozniak et al., 1999), which raises issues of (a) the possible etiologic and exacerbating role of abuse in the development of ADHD and (b) the potential for abuse-related post-traumatic responses being misdiagnosed as ADHD. Our key objectives were to examine whether girls with ADHD were at increased risk of having histories of abuse and to assess whether those with abuse histories may constitute a distinct subgroup. We focus on the understudied population of girls with ADHD, given the clinical and conceptual importance of this group (Hinshaw & Blachman, 2005). Our objective is not to investigate the prevalence of abuse within a normative sample (e.g., Finkelhor, Ormrod, Turner, & Hamby, 2005) but, within a clinical sample, to examine clinical presentation and levels of crucial impairments when abuse and ADHD co-occur. We examined girls with ADHD because of the underrepresentation of females in extant research and because of the availability of the large data base that we have gathered on a well-characterized female sample (Hinshaw, 2002).

Increased aggression and externalizing problems, including hostility, difficulty with anger management, impulsivity, and physical attacks (Widom, 1997) are clearly linked to abuse (Cicchetti, Rogosch, Lynch, & Holt, 1993; Deater-Deckard & Dodge, 1997; Margolin & Gordis, 2000; Osofsky, 2003, Widom, 1997). Physical abuse has been most strongly and specifically linked to externalizing problems (Margolin & Gordis, 2000); sexual abuse has been more directly linked to childhood PTSD symptoms and later internalizing symptoms (Kendall-Tackett, Williams, & Finkelhor, 1993; Whiffen & MacIntosh, 2005). Yet sexual abuse predicts such specific externalizing behaviors as sexualized talk, preoccupation with sexual themes, sexual aggression toward other peers, and provocative behaviors at early ages, collectively termed “sexual acting out,” (Gil & Johnson, 1993; Margolin & Gordis, 2000).

Next, abuse is often damaging to a child's self-perceptions and perceptions of the world, resulting in learned helplessness, anxiety, and depression (Kazdin, 1985), even to the point of increased self-destructive and suicidal behavior (Widom, 1997). Abused children also show evidence of poor social interactions and peer relationships. They are rated by their peers as more rejected, less popular, and more disruptive than children who have not been abused. Parents and teachers also rate abused children as socially rejected. Finally, abuse (Osofsky, 2003, Widom, 1997) and neglect (Margolin & Gordis, 2000; Osofsky, 2003) have been linked to both poor academic functioning and delayed cognitive development. On tests of verbal ability and comprehension, both physically abused and neglected children tend to score lower than non-abused comparison children. In sum, abused children present with externalizing and internalizing difficulties, compromised peer relations, and academic/cognitive impairments, yet specific mediators of such associations have yet to be elucidated.

ADHD is a childhood disorder characterized by impairing and developmentally extreme levels of inattention, impulsivity, and hyperactivity and yielding a prevalence of 3–7% (American Psychiatric Association, 2000). It is predominantly a male disorder, with male to female ratios approximating 3:1 in the population at large (Hinshaw & Blachman, 2005). The study of ADHD has been overwhelmingly based on male samples, with focus on girls emerging relatively recently (Arnold, 1996; Gaub & Carlson, 1997; Hinshaw & Blachman, 2005).

ADHD affects children in many domains, including those that closely parallel the above-noted examples related to abuse: externalizing difficulties (Hinshaw, 1987), internalizing problems (Jensen, Martin, & Cantwell, 1997), compromised peer relationships (Hinshaw & Melnick, 1995), and problems in cognitive ability/academic performance (Hinshaw, 1992). The extensive literatures on each of these domains of impairment are vast. Indeed, the impairments related to ADHD are substantial and rates of comorbidity with both disruptive and internalizing disorders are far above chance (Angold, Costello, & Erkanli, 1999). Furthermore, peer rejection places children at substantial risk for continued social problems, academic underachievement, and behavioral problems (Parker & Asher, 1987), meaning that the impairments related to ADHD are probably overdetermined.

ADHD is a condition for which high rates of heritability and evidence of neurobiological underpinnings strongly suggest neurodevelopmental origins (Tannock, 1998). This assertion is not meant to imply that school and family environments are unimportant in the development or maintenance of ADHD (Hinshaw, 1999); rather, it indicates that parenting is not likely to be a primary cause of ADHD. In addition, given the genetic underpinnings of many cases of ADHD, biological parents of children with ADHD are likely to show impulse control and attentional problems themselves (see review in Johnston & Mash, 2001), possibly increasing the likelihood of abusive behavior.

A substantial literature reveals that parents of children with ADHD experience more stress and more dysfunctional parent/child interaction styles than do parents of children without ADHD (Anastopoulos, Guevremont, Shelton, & DuPaul, 1992; Anderson, Hinshaw, & Simmel, 1994; Fischer, 1990; see review in Johnston & Mash, 2001). Furthermore, parents of children with ADHD report increased feelings of self-blame, incompetence, depression, and isolation (e.g., Nigg & Hinshaw, 1998). Not surprisingly, mothers of hyperactive children are separated or divorced more frequently than mothers of children without ADHD (Fischer, 1990).

We have asserted that abuse and ADHD share the common features of externalizing and internalizing behavior problems, peer rejection, and cognitive difficulties. Furthermore, child abuse is defined by inappropriate reactions on the part of adults (often parents) against children, and families of children with ADHD are marked by dysfunctional interactional patterns. These similarities raise the question of a possible link between these two phenomena as well concerns about the differential diagnosis and treatment of each problem.

Wozniak et al. (1999) investigated whether children with ADHD are at increased risk of suffering from trauma as well as PTSD and related psychopathology. Their definition of trauma included child abuse as well as other traumatic events like accidents, combat, medical catastrophes, and physical attacks. They concluded that there were no meaningful associations between ADHD, trauma, and PTSD. They did not disaggregate their data by category of traumatic events, however, our examination of their tabulated data reveals that that 7% of their ADHD population had suffered from child abuse (including sexual abuse, physical abuse, and witnessing domestic violence) compared to .1% of their comparison sample. Also, they excluded adopted children, possibly leading to lowered rates of abuse. Thus, their methods may have limited chances for finding links between abuse and ADHD.

Ford et al. (2000) examined the relationship between trauma exposure and both ADHD and oppositional defiant disorder (ODD). After screening admissions in an outpatient psychiatric facility for ADHD and ODD, they assessed children's exposure to trauma and PTSD-related symptoms. Trauma was strongly linked to ODD: 45–73% of the ODD sample had been exposed to physical maltreatment, and 18–31% had been sexually maltreated. In contrast, 25% of the ADHD children were exposed to physical abuse and 11% exposed to sexual abuse. Tellingly, 91% of children with comorbid ADHD and ODD had a history of trauma (Ford et al., 2000). Thus, comorbidity of ADHD and disruptive behavior disorders may be a particularly strong correlate of abuse histories.

Our first purpose was to extend a preliminary, descriptive finding of Hinshaw (2002) by examining whether a carefully diagnosed sample of preadolescent girls with ADHD showed higher rates of documented abuse than a matched comparison sample. Our second and more crucial objective was to document whether the subgroup of girls with ADHD and documented abuse was more impaired, in terms of externalizing and internalizing behavior problems, peer relations, and cognitive functioning, than the non-abused ADHD subgroup. We hypothesized that the ADHD-abused subgroup would display substantial impairments in each domain. A key feature of this investigation is the availability of multi-informant and multi-method data on key impairments. In addition to parent, teacher, and staff ratings, these included objective observations of externalizing behavior, validated self-reports and observations of internalizing behavior, peer sociometrics (as an indictor of social relations), and standardized cognitive tests. Finally, to elucidate relevant interactive processes and mechanisms, we examined whether any established linkages between abuse and peer rejection were mediated by tendencies of the abused subgroup to display aggressive behavior patterns. Because aggressive behavior has been causally linked to the development of peer rejection (e.g., Erhardt & Hinshaw, 1994), we tested whether aggressive behavior might account for association between abuse and negative peer status.

Section snippets

Overview of procedures

The present research was conducted as part of a 3-year, National Institute of Mental Health (NIMH)-funded, series of summer camp investigation of girls with ADHD, held in 1997, 1998, and 1999 (see Hinshaw, 2002, for details). After initial recruitment and screening of participants, written consent was obtained and families came to campus for an extensive in-person evaluation during which assessments of IQ and academic achievement, as well as interviews and checklists of internalizing and

Results

Of the 24 cases with abuse histories, four were comparison girls (4.5% of comparison sample) and 20 were girls with ADHD (14.4% of the ADHD sample). The chi-square test of this difference was significant, p < .05. The odds ratio was 3.5. As shown in Table 2, the ADHD sample had numerically higher rates of all types of abuse, most notably neglect and sexual abuse.

The focus, therefore, shifts to how the abused group of girls with ADHD differs from the girls with ADHD without histories of abuse.

Discussion

We examined the rates of child abuse in a large and diverse sample of preadolescent girls with and without ADHD. First, we found that the girls with ADHD were at increased risk of having abuse histories. Second, those girls with ADHD and a history of abuse were distinct from their ADHD counterparts in terms of their levels of externalizing behavior and peer rejection. Specifically, the abused ADHD subgroup was viewed as significantly more aggressive according to parent, teacher, and peer report

Acknowledgements

We thank the girls and families who participated in our summer research programs and the research coders who diligently aided in the preparation of the data. We give special thanks to Elizabeth Owens for help with data analyses.

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    Work on this article was supported by National Institute of Mental Health Grant 45064, awarded to Stephen Hinshaw, and an Underrepresented Minority Supplement to this grant, awarded to Allison Briscoe-Smith.

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